History of the British Association for Community Child Health

History of the British Association for Community Child Health (BACCH) formerly the Community Paediatric Group (CPG)

Introduction BACCH is the largest specialty group within the Royal College of Paediatrics and Child Health (RCPCH) and this chapter reviews the origins of BACCH and its influence both within the College and on the development of community child health services for families throughout the UK. Central to the development of community child health services has been the development of leadership and clinical expertise through the appointment of Consultant Paediatricians in Community Child Health (CPCCH) and then the development of subspecialty interests within community child health, such as disability, public health, audiology, child protection and child mental health, in order to meet the ever changing morbidity in childhood. BACCH continues to advocate for family centred care provided in local communities, promoting health using a life course approach and service development based on pathways, delivered by team working in networks which strive for continuous quality improvement in experience and outcomes. To achieve this BACCH works closely with other professional groups within health and other agencies and with the RCPCH.

History The history of BACCH must be viewed simultaneously alongside the position of children in society and changes in childhood morbidity, the wider socio-political changes of the late 20th century, particularly reorganisation of the National Health Service (NHS), with more community-based service provision coupled and newly available health interventions. The roots of Community Child Health started with public health interventions of the late 19th century and with a medical and nursing workforce which expanded throughout the mid-20th-century with a peak in the 50s and 60s. This workforce was employed by Local Authorities, often led by community specialists and it was not until the 1974 reorganisation that this workforce joined the NHS. The history of BACCH is essentially the story of how the work of this community child health workforce evolved and became integrated into the NHS and this chapter is presented in three decades.

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1976-1985 the beginnings The publication in 1976 of "Fit for the Future" the Report of the Committee on Child Health Services chaired by Donald Court was the seminal point in the development of Community Child Health services as we know them today. The report acknowledged the health gains made by children over the previous century but looked to the future and recommended improved community-based, integrated care, led by paediatricians, particularly for children with long-term conditions. The origins/initiation of the British Association for Community Child Health (BACCH) were recorded as a request from John Davies, then chair of the Academic Board of the British Paediatric Association requesting that the BPA "wanted to have contact with, and at times advice from, a group of community paediatricians. Such a group would be associated, but not part of the BPA". Frank Bamford took this forward during the BPA meeting in Harrogate in April 1974 when he met with a small group of like-minded paediatricians to propose the "British Association of Community Paediatrics" whose first formal meeting was on 23 October 1974. The stated purpose of the group was "to contribute to the improvement in the care of all children, to promote scientific study of clinical community paediatrics, to facilitate the exchange of knowledge, information and ideas among its members and to disseminate knowledge of clinical community paediatrics" (the word children includes adolescents). However, the British Paediatric Association objected to the title of "British Association of Community Paediatrics" and after protracted discussions over two years, the name was amended to the Community Paediatric Group and finally adopted on 11 November 1976. The group remained independent of the BPA until 1984 when the BPA formally recognised the CPG by setting up a BPA Liaison Group "to consider issues relating to community paediatrics". During this first decade, the Community Paediatric Group spent considerable time defining the role and duties of a consultant paediatrician in community child health and lobbying the BPA to include community child health as a legitimate specialty within paediatrics. While the BPA paper "Paediatric manpower: towards the 21st century" in 1984 acknowledged roles of consultant community paediatricians, they also assumed these consultants would contribute to the acute hospital call rota, thus effectively transferring community resources into hospital settings. The other problem revolved around the fact that the majority of doctors (CMO's and SCMOs) working in community settings with children often had no formal postgraduate qualifications other than experience and on-the-job training. The BPA as the "governing body" for the education and training of paediatricians did not feel these doctors were "paediatricians" and as the majority were not members of the BPA they did not feel responsible for their education and training. The CPG repeatedly described the role of a Consultant Paediatrician in Community Child Health (CPCCH) in the early 80s but it was not until the Child Health Forum produced a report in 1988, linked to the BPA Census, which identified 47 CPCCH (working more than five sessions a week in community child health) recommended one CPCCH per district and recognised that further expansion would be required in the future, that the BPA acknowledged the need for workforce planning and formal training programmes for these consultants.

1985-1994 development of community child health Having proved the need for CPCCH the Joint Committee on Higher Medical Training (JCHMT) of the Royal College of Physicians (London) produced a model training programme which in 1985 enabled the development of senior registrar training posts. The mismatch between people in training and the numbers of senior doctors retiring from established community child health departments soon became apparent. The CPG responded by producing a number of workforce planning documents throughout this decade arguing for an expansion of both consultant numbers and training programmes.

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One particular area of concern was of public health. After lobbying the BPA and Faculty of Community Medicine a joint working party was formed to examine the interface between public health and child health. The outcome was a paper entitled Working “Together for Tomorrows Children” in 1998 which helpfully defined the needs of local populations and the roles and responsibilities of each professional group. 1989 saw the publication of the first of the “Hall reports” (Health for All Children) covering preschool child health surveillance. This was one of the earliest reports to apply evidence-based medicine approaches to clinical services to create a national framework for preschool surveillance. The initial report focused on the screening components within child health surveillance and acknowledged that the evidence-base for many of surveillance and promotion activities was lacking. The result was that child health surveillance was cut back to the core of what was considered essential. From the perspective of community child health services this was the start of a major evolutionary process from a comprehensive public health orientated, whole population service delivered by a combined workforce of largely clinical medical officers, health visitors and school nurses, to a secondary care community child health service focusing on long-term conditions and vulnerable families, delivered by consultant paediatricians, staff and associate grade specialists and increasingly trainees. All the routine surveillance and health promotion would eventually transfer to primary care teams, and all the Local Authority specialist services largely integrated into hospital-based care, for example orthopaedics. The acceptance and endorsement of the role of consultant leadership within community child health services led to the transition of the Community Paediatric Group into the British Association for Community Child Health in 1992. The change of name (‘for child health’) was a deliberate emphasis to focus on improving child health rather than representing the interests of paediatricians (‘of community paediatricians’) or a focus on disease (‘of community paediatrics’). The reasons for the change of name eventually influenced the name and focus of the BPA as it transitioned to later become the Royal College of Paediatrics and Child Health thanks to the influence of David Baum, who had been the Chair of BACCH before becoming President of RCPCH. One of the first publications of BACCH produced was a detailed syllabus of training, based on knowledge and skills, to guide the expansion and training of senior registrars in community child health. BACCH also produced a number of workforce planning documents indicating the number of senior registrars required to replace retiring Senior Clinical Medical Officers (SCMOs). This initiated a prolonged regrading process of SCMOs (Child Health) into CPCCH posts. The 1990 NHS and Community Care Act introduced of the NHS internal market with GP fundholders and created considerable anxiety for those providing services not primarily driven by GP referrals. The response from BACCH was to produce a guide for purchasers and providers entitled "Services for Children" a model for purchasers and paediatricians in 1994 which laid down an approach based on pathways of care, provided by five teams covering acute and long-term illness, disability, social paediatrics, behavioural paediatrics and public health; this framework was adopted by the National Service Framework 15 years later. As consultant leadership of these teams developed the need for, and roles of specialist expertise within community child health became apparent. The BPA was unwilling to recognise the specialist groups within community child health and so it was agreed that BACCH would act as an umbrella organisation to represent these interests. The development of specialty groups in some ways mirrors the development of BACCH starting with a few enthusiasts developing the specialty, recognition of that specialty and then the need for training and accreditation, followed by workforce planning and practical service delivery. The British Academy of Childhood Disability was first to gain RCPCH specialty recognition. The two-day Annual Scientific Meeting of BACCH allows specialty groups the opportunity to present

Page 3 of 6 History of the British Association for Community Child Health both research and share best practice in their areas as the majority of CPCCH are generalists. The BACCH response to the Calman training reforms in 1994 was to develop programs where generic community child health training occurred over two years, with a third year within a chosen specialty.

1995-2004 Embedding Community Child Health This decade started with the publication of the Polnay Report, Health needs of school age children in 1995 which extended the preschool focus in Health for All Children up into the school age. The conclusions were that routine surveillance was outdated and the service should concentrate on those children with medical, social or psychological problems. The role of the school nurse was promoted and the role of the school doctor contracted and was no longer school-based. The upheaval in provision of preschool and school health provision was followed in 1996 by the Department of Health publication "Child Health in the Community: a guide to Good Practice" led by Jerry Reid which, for the first time the Department of Health attempted to establish uniformity of the provision of community child health services in the UK. 1996 saw the formation of the RCPCH which was a milestone for the development of community- based services for children and families since child health was firmly included within the remit of the new college. The publications by the RCPCH in early 2002 of "The Next 10 years: Educating Paediatricians for New Roles in the 21st Century" and the report "Strengthening the Care of Children in the Community a Review of Community Child Health" both acknowledged that the boundaries between hospital-based and community-based practice were becoming increasingly blurred and that training in community child health, particularly relating to the sub specialist areas notably, disability, child protection and social paediatrics, child mental health and educational medicine, and child public health required further attention and investment. Additionally for the first time there was discussion about the configuration of paediatrics and health services and the need for reconfiguration and a comprehensive workforce review covering community, hospital and specialist paediatric workforces.

2005-2014 improving community child health This decade started with the publication of the Children and Young People's National Service Framework from the Department of Health (DH) and the Children Act from the Department of Education and Skills (DfES). The Children and Young People's NSF had reinforced the need for integrated working in teams crossing primary, secondary and tertiary healthcare and between health, education, social care and the voluntary sector. Services planned, delivered and improved based on pathway approaches, delivered by teams working in partnership with families were recommended. BACCH worked closely with the RCPCH in producing Modelling the Future which consisted of three linked publications between 2007 and 2009 outlining the need for the reconfiguration of services, reduction in the number of units providing inpatient care, development of more comprehensive community services and investment in quality improvement and learning especially in times of change. The 2012 Health and Social Care Act replaced 152 primary care trusts with 211 GP led Clinical Commissioning Groups and a single NHS Commissioning Board for . The impact was that many community child health services previously hosted by primary care trusts had to find new organisations to host their services. Some elected to merge with hospital services, others formed social enterprise organisations, while others merged with existing community-based organisations. The transfer of Public Health functions (in England) to Local Authorities and the loss of relationships with previous commissioners within PCT's has created considerable concern, as the focus of the new commissioners was largely on high cost secondary care rather than balanced with improving the health of the local population.

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The response from BACCH was the publication of the "Family Friendly Framework" in 2011 which illustrated how services should be commissioned, delivered an improved based on pathways and networks and then this was complemented by the BACCH Prospectus for commissioners in 2012, which provided a detailed description of community child health services including a brief epidemiology of conditions, the role of paediatricians and potential areas for improvement.

2015 and the future of community child health The need for "joined up" integrated thinking has been repeatedly called for over 30 years, especially in the world of child protection/safeguarding and yet the principal is as equally important for mental health and public health. This remains a challenge which has not yet been successfully overcome, so BACCH produced a paper “ The Meaning of Integration for Children and Families ” in 2012, in an attempt to create alignment and synergy between commissioners, providers and the interests of CYP. There continues to be sustained interest in the model of pathways and networks first advocated by BACCH in 1994 and the full potential of such approach has not yet been researched and embedded throughout clinical services. In order to support more specialist care within community settings, such as disability, mental health and vulnerable children’s services, community child health departments will have to become larger and/or develop more collaborative approaches with adjacent departments. Ever better antenatal-neonatal care should improve outcomes and genetic engineering may reduce the frequency of long-term disabling conditions and be able to predict the likelihood of adult disease earlier in life; but poverty and inequalities and their impact on life course pathways and illness are likely to continue for many years yet and will require proactive Public Health approaches to both promote and protect the health of the least well-resourced in society. Predicting future morbidity will always be difficult, in 1976 the current concerns of inequalities, ADHD/ASD, obesity and mental health problems were not high on the agenda, today the expectation of perpetual economic growth is not compatible our planetary ecosystem and we are beginning to see climate change related health issues such as extreme weather events, economic migration and in some parts of the world reduction in local food production and emergence of new communicable diseases. From health service perspective future services must be able to adapt more flexibly than they have in the past both to new research and developing technologies, must become more person centric and embrace quality improvement strategies that embed learning within the service delivery. There is still further potential in developing comprehensive, family orientated, community-based teams centred based on primary care hubs, but with greater expertise, a wider set of competencies and broader skill mix than currently exist. Such a team could reduce unnecessary referrals to hospital and improve the quality of care for those children with long-term conditions. BACCH will continue to advocate for improved health and health services for children and families throughout the UK for the foreseeable future.

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Chairs of CPG/BACCH • 1975 Frank Bamford (initial meeting) • 1975 Rosemary Graham • 1979 E. Ellis • 1983 Neil Gordon • 1987 Ross Mitchell • 1991 David Baum • 1995 Leon Polnay • 1999 Jo Sibert • 2001 Nick Spencer • 2005 • 2009 Simon Lenton • 2013 Gabrielle Laing

BACCH affiliated groups • The British Academy of Childhood Disability (BACD) acts as the UK branch of the European Academy of Childhood Disability. www.bacdis.org.uk • The British Association of Paediatricians in Audiology (BAPA) former British Association of Community Doctors in Audiology (BACDA). www.bapa.uk.com • The Child Protection Special Interest Group (CPSIG) The Group works closely with the RCPCH Child Protection Standing Committee www.cpsig.org.uk • The British Association for Child and Adolescent Public Health (previously known as the Child Public Health Interest Group) www.bacaph.org.uk • The Paediatric Mental Health Association (PMHA) www.pmha-uk.org • The George Still Forum www.georgestillforum.co.uk • Scottish Association for Community Child Health (SACCH) www.bacch.org.uk/links/SACCH.htm

Dr Simon Lenton August 2016

A version of this document appears as a chapter in the RCPCH publication ‘History of the RCPCH’ (2016).

British Association for Community Child Health 5-11 Theobalds Road London, WC1X 8SH

Tel. 020 7092 6082/4 Email. [email protected] www.bacch.org.uk Twitter @CommChildHealth BACCH is an incorporated charity limited by guarantee in England & Wales: Charity number: 1129758, Company number: 6738129

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